Gastroesophageal Reflux Disease (GERD)

Gastroesophageal Reflux Disease (GERD)

One of the most common maladies of the esophagus is gastroesophageal reflux. In 20% of the population, this is usually manifested as heartburn or regurgitation. A smaller percentage of patients will have symptoms of chest pain, cough or hoarseness.

The diaphragm and the lower esophageal spincter (LES) act as barriers to prevent stomach acid from coming up into the esophagus (reflux). A hiatal hernia occurs when the opening of the diaphragm is too large and the top of the stomach can slide up and down into the chest. When this happens, the esophagus cannot strip the acid well and the effect of the diaphragm in preventing reflux is lost.

A color illustration depicting a hiatal hernia.

Hiatal hernias may be seen on X-rays or during an upper endoscopy in patients who have no symptoms.
In many patients with gastroesophageal reflux disease (GERD), the LES will relax at inappropriate times; in others, the LES pressure may be too low to prevent the reflux of stomach contents.

The most common symptom of reflux disease is heartburn. Most adults experience heartburn in relationships to specific foods or large meals. If this reflux occurs on occasion, related to such factors, avoidance is the usual treatment. General measures of treatment also include avoidance of foods such as chocolate, peppermint, fatty foods, and alcohol … all which can cause reflux.

Gravity assists drainage of the esophagus, so your doctor may suggest that you elevate the head off the bed six inches. As well, eating small meals instead of large ones, and not eating within three hours of lying down might be helpful.

An illustration comparing an esophagus with a normal gastroesophageal sphincter and one afflicted with gastroesophageal reflux disease.

Patients who are overweight may be asked to lose weight to avoid pressing the stomach contents into the chest.

Occasional use of antacids is acceptable; however, if symptoms persist daily, physicians may recommend medications to suppress acid formation (i.e. Tagamet, Axid, Zantac, Prilosec, Prevacid, Nexium). As a first line of treatment, doctors may use medications to increase the tone of the LES or improve the stripping motion of the esophagus (i.e. Reglan, Domperidone).

Patients who have frequent reflux or who have atypical manifestations may be asked to have an upper endoscopy to look for complications of reflux.

Patients with atypical manifestations of GERD include those with chest pain not attributable to the heart, hoarseness and coughing. These patients often require combinations of medications for treatment, and they may require higher doses of medications. To look for evidence of GERD as a cause of these type symptoms, patients may have a test called a pH study. In this test, a very small probe (about the size of two pieces of spaghetti stuck together) is inserted through the nose and into the esophagus. This is left in place for 24 hours. A diary of symptoms is kept by the patient to see if the symptom corresponds to the reflux of acid.

Surgery for the treatment of reflux is considered when a person requires large doses of medications, the medications are insufficient, or the patient cannot tolerate the medications, especially young people who are considering the potential of life-long medical treatment.

The classic surgery involves wrapping the top part of the stomach around the junction of the esophagus and stomach (Nissen fundoplication). This corrects hiatal hernias and prohibits acid regurgitation. This type of surgery is typically performed laparoscopically. Variations of the Nissen fundoplication usually reflect how much of the stomach is wrapped around.

In considering surgery, it is important for patients to have a measurement of their muscle function and coordination in the esophagus. An esophageal manometry is a test in which a small tube is inserted into the nose and the pattern and pressure of peristalsis is recorded. This test tells the physician whether the patient is at risk for difficulty swallowing after surgery and is also used to diagnosis illness other than acid reflux that cause similar symptoms.

Chemotherapy combined with radiation to the esophagus has been used with success to improve the ability to swallow. This combination may also be given to patients who are good surgical candidates but have cancer that goes deep into or through the esophageal wall or involves local lymph nodes. After treatment, surgery can be reconsidered.

Radiation treatment by itself is used usually only if the cancer is very advanced. A wire tube (stent) may be placed across the narrowed area of the esophagus to improve swallowing or to close off a hole if the tumor has spread to connect the esophagus with the airway (tracheoesophageal fistula). Stents are used for patients with advanced disease or for those who cannot tolerate surgery or the chemotherapy/radiation combination. This may also be offered to those patients who don't want surgery or chemotherapy.
Adenocarcinoma of the esophagus is felt to arise primarily in those who have developed Barrett's Oesophagus. The symptoms and treatment are similar for squamous cell carcinoma, although some believe that radiation therapy is less effective.